HomeMy Public PortalAbout9415 GIDLEY ST_Mechanical__ • doMPENSATION DECLARATION APPLICATION FOR PERMIT
h m that y have a certificate of consent to self
IrtLu or a�erttflc$te of Workers' Compensation Insurance,
or a Artifled df�y thereof (Sec. 3800, Lab. C.) HEATING - VENTILATING - AIR CONDITIONING
�eAawc
* CE-818(REV. 10/81)
Policy No. 4 Company
Certified copy Is hereby furnished. COUNTY OF LOSANGELES BUILDING AND SAFETY
❑ Certified copy Is filed with the county building Inapec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALE Y
NO. TYPE OF APPUAN�-E OR EQUIPMENT FEE
CERTIFICATEOF EXEMPTION FROM WQRURS' NST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed If the work Involred by ABSORPnON UNIT, BTU DISTRICT NO. M0a'S ID BY
the permit Is for one hundred dollars (:100)or less.) !/1
I certify that In the performance of the work for which this AIR HANDLING UNITCFM V
permit Is Issued, I shall not employ any tsorrin any manner
so as to become subject to the Workers Compensation Laws. BOILER, BTU APPROVALS TE S RE
d COMPRESSOR, BTU
bate, /Zppl Ica nt
NOTICE TO APPLICANT: If, after making this Ce Ifl of VBJST
T LAT10N SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Lob-or Code, you must forth- EVAPORATTVE CQDLER VALI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am Ilcensed Under provisions of Chapter 9 HEATER: SUSPENDED UNff
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license Is In full force and effect. d
O
Llcerse Number Llc. Class ► U
OC
Contractor Date O
❑ 1 am exempt under Sec. su
Plan chock fee
B.BP.C. for this reason
PERMIT ISSUING SEE ;
Date:
TOTAL FEE'
Signature
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Busine" and NAME
professions Code):
X769."1 A
❑ I, as owner of the property, or my employees with 'ADDRESS
wages as their sole compensation,will do the work and # 0:0,0 0 0 8
NO
the structure Isnot Intended or offered for sale(Section .
7044, Buslness-and Professions Code). I .°.Q 4 Q5 0
OWNER
❑ I, as owner of the property, am exclusively contracting MAIL 0 0 0 4(15,0 F3
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CTY TEL id0. Q 1 7 8 7
1 hereby affirm that there Is a construction lending agency for '
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec. 3097,Civ. C.).
ADDRESS
Lenders Name
CITY TEL NO.
Lender's Address
STATE LIC
I certify that I have read this application and state that the U NO. CLASS-
above Informatlon Is correct. 1 agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentionproparty for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'�2-7�
Signature of Applicant w Wnt Date
"'°' 'S COMPENSATON° 's,nt to °�'9'8° APPLICATION FOR PERMIT- L1 �•` .�RE�
I
hereby affirm that I have a certificate of oonaent to self Insure,
ova cettlilcate of Workers Compsnpetlo6 Insurance, or a certlfled. MFJITING=VE MLATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.'C.)
QNo.-- c«npe� COUNTY OF LOS AINGELES DEPT OF PUBLIC WORKS BUILDING AND SAFn-Y DIV.
Cmtrlea copy is hereby hrmwmd.
raw be Mid with the c=ity buddIng by peatton., FOR APPLICANT TO FILL IN
(PR NT OR TYPE ONLYf
LocALrrY �' G
Det. APPllicart NO. TYPE.OF APPLIANCE OR EQUIPMENT FEE
..CERTIFICATE.QF DC AIPTION FROM WOMB CAST.
COMpE]JSAT]OfJ INSURANbE AB90RPTION UNIT aTu
(mu"Oron n"d nQt bd.:oompleted f(the'
wort Irtrohnd by the MAP . PAGE PAAa
C -
permit is fon one hundred dolLsT({100)or work
AIR l lAH°uNG LWT CFM
DWrFICT MID. .
F o*MI-fy that In'The performance of the work for whloh thlt permit
Is Issued, I shall'hot'employ any person In any manner so-as toBOCER,BTU
become sub)eot to the Workers' CompensaUon Laws: e�
COM SIU L.
APP"AM DATE *am nt-rows SaWTUm
Dem c 3 App�oarrt V17JIILATbN SYeTE]E ..
NOTIC TO tt APPLICANT: ar making thlb CertIcdts of ROUGH
Exemption,you shoukt become subject to the Work"'Compensation EVAPORATIVE C0041ER
provisions of the Labor
-Qode,.you must-forthwith comply wkh such FINAL fQ
provlstons or this permit shall bf deemed reyoked. FUFtNAC>= FAU_7GFIAVITY Q� s
LjcENsED CONTRAL rofiS DECLARATION I FLOOR' BTU V '(AT-ON
I hereby aMfm that I am Iloensed under proYlslons of Chapter D HEATER S118P13DED
(commencing with 9sctlon 7000}of Divlslpn 3 of the Business,and WALL
Prdfeasbna Code, end m Ilcense Is.l Tull force and effeoL
r
Lkxtrm NLrmt Class ;
Plan check fee _
I am Tempi u [[
B`dP.C.for U*reason PERIAIT ISSUING FEE$_ Q'
Date: TOTAL FEE
-Ti. 6_ LU
Bignstu
n -
OWNEP,BUILDER DECLARATION PLAN CHECK APPiJCANr Z
I hereby dtflrm that I am exbmpt from the Conbvctor's License Law NAJ,E
for the following reason (Seatlon 7031.6, 9uslnees and Profeealons '
Code): ADDFE88 ur `
I, as o*ner of the property, or my employees With wages tt`•1rT'i
as thblr sole c6hlpenoation, will do the_work and the CITY TEL..NO. 7.�77.7
;f"
structure Is not Intended or offered for sale (Section 7044, T
Bustnase.and Prpisesions Cpds). OWN�I
I,
to owner of the property, am exolue)vely contracting AWLTOTAk ,. 77 . '7V
with licensed contfactors to construct the project (Seo- ADOFESg �y_�!/W�y� T1 �n
tion 7044, BuslrHw and Profeselons Code). CITY TEL NO.' .TC4it: f f.■1 V
CONSTRUCTION LENDING AGENCY
£ r
I-herebyy affirm that thTOR
ere In construction lending g enoy for /� `
the performanoe oT the work for whioh this permit Is Issued - �ly■ (�O
(Sec.3087, Civ.C.). F
. E68- 1 11M./93.L�M{i fo
L.enADDA
dera Name la)0-.300l 1 . 7,j.
Ery �./� TEL.No. — 1 AI'{11:06
Lenders Address STATE LIC.
I certify that I have read this appllcoon and state that;the.above• L]CI z NO. CLA88
Infonmadon Fe obnvelL I epee to compty with ell County ordfiancee
and State lawn re4dW to twfldtng gonstuc don,and hereby duthorin
repreeentativea of This County bo enter upon the above-mentioned
property Yr Inspe.0tlonn_purppoos". 13FE REVEFtBE FOR EXPLANATORY LANOUAW
pbaMTU Fig OF APPUCM T OR MEW